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<table width="437" border="0" bgcolor="#66CCFF" align="center">
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    <td width="431" colspan="7"><img src="Encabezado.png" width="383" height="88" /></td>
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    <td colspan="7
    " align="center" valign="middle"><strong>REGISTRO DE SOLICITUD DE SERVICIO</strong></td>
  </tr>
  <tr>
    <td colspan="7"><form id="form1" name="form1" method="post" action="">
      <table width="431" border="0" align="center">
        <tr>
          <td colspan="5" valign="middle"><strong>CLIENTE</strong></td>
          </tr>
        <tr>
          <td colspan="2" valign="middle">Cliente: 
            <label for="textfield"></label></td>
          <td colspan="3" valign="middle"><input name="textfield" type="text" id="textfield" size="50" /></td>
          </tr>
        <tr>
          <td colspan="2" valign="middle">Num ID: 
            <label for="textfield2"></label></td>
          <td width="180" valign="middle"><input name="textfield2" type="text" id="textfield2" size="30" /></td>
          <td width="52" valign="middle">Tipo:
            <label for="select"></label></td>
          <td width="67" valign="middle"><select name="select" id="select">
            <option>RUC</option>
            <option>DNI</option>
          </select></td>
          </tr>
        <tr>
          <td colspan="5" valign="middle"><strong>DESTINATARIO</strong></td>
          </tr>
        <tr>
          <td colspan="2" valign="middle">Destinatario: 
            <label for="textfield3"></label></td>
          <td colspan="3" valign="middle"><input name="textfield3" type="text" id="textfield3" size="50" /></td>
          </tr>
        <tr>
          <td colspan="2" valign="middle">Num ID: 
             
            <label for="select2"></label></td>
          <td valign="middle"><input name="textfield4" type="text" id="textfield4" size="30" /></td>
          <td valign="middle">Tipo:</td>
          <td valign="middle"><label for="textfield8">
            <select name="select2" id="select2">
              <option>RUC</option>
              <option>DNI</option>
            </select>
          </label></td>
          </tr>
        <tr>
          <td width="111" valign="middle">Dirección:
            <label for="textfield5"></label></td>
          <td colspan="4"><input name="textfield5" type="text" id="textfield5" size="50" /></td>
          </tr>
        <tr>
          <td colspan="5"><strong>MERCADERIA</strong></td>
          </tr>
        <tr>
          <td height="30" colspan="5">Origen 
            <label for="select3"></label>            <select name="select3" id="select3">
              <option selected="selected">Lima</option>
              <option>Piura</option>
              <option>Trujillo</option>
              <option>Arequipa</option>
              </select>
            Destino
            <label for="select5"></label>            <select name="select4" id="select4">
              <option>Arequipa</option>
              <option>Lima</option>
              <option>Trujillo</option>
              <option>Piura</option>
            </select></td>
          </tr>
        <tr>
          <td>Fecha 
            <label for="textfield6">:</label></td>
          <td colspan="4"><input type="text" name="textfield6" id="textfield6" /></td>
          </tr>
        <tr>
          <td>Producto 
            <label for="textfield7"></label></td>
          <td colspan="4" valign="middle"><input type="text" name="textfield7" id="textfield7" />
            <input type="submit" name="button" id="button" value="Agregar" />            <input type="submit" name="button2" id="button2" value="Eliminar" /></td>
          </tr>
        <tr>
          <td colspan="5"><table width="404" height="52" border="1" align="center">
            <tr>
              <td bgcolor="#999999">Item</td>
              <td bgcolor="#999999">Productos</td>
              <td bgcolor="#999999">&nbsp;</td>
            </tr>
            <tr>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
              <td>&nbsp;</td>
            </tr>
          </table></td>
        </tr>
        <tr>
          <td colspan="5"><blockquote>
            <blockquote>
              <blockquote>
                <p>
                  <input type="submit" name="button3" id="button3" value="Aceptar" />            
                  <input type="submit" name="button4" id="button4" value="Cancelar" />
                </p>
              </blockquote>
            </blockquote>
          </blockquote></td>
          </tr>
      </table>
      <label for="textarea"></label>
    </form></td>
  </tr>
</table>
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